Putting on a Clinic
Design and Operate a Successful Mass COVID-19 Vaccination Program in the Workplace
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The COVID-19 pandemic has put an unprecedented demand on existing healthcare infrastructure. As a result, alternative care sites have been identified or established to support the medical community, ranging from convention centers to school gymnasiums and parking lots. Federal- and state-administered programs extended this model to support community-based COVID-19 vaccine distribution. However, as fewer people sought inoculation, the number of mass vaccination sites decreased.
At the time of this writing, the United States was experiencing a surge of infections due to widespread vaccine hesitancy, the rise of SARS-CoV-2 variants, breakthrough infections, waning immunity, and the vulnerability of young children not yet eligible for vaccination. In response, executive orders were signed in September 2021 mandating all federal and contract staff within the executive branch be vaccinated against COVID-19. In November 2021, OSHA issued an emergency temporary standard requiring employers with more than 100 employees to implement a COVID-19 vaccination policy or ensure employees are tested on a weekly basis. (Editor’s note: The Supreme Court is currently hearing challenges to the ETS.) These actions, along with new requirements for employees at healthcare facilities receiving Medicare and Medicaid payment, are estimated to affect 100 million workers—two thirds of the nation’s workforce. An alternative framework for delivery of mass vaccination and booster doses should be established to minimize additional strain on the U.S. public health system. One such avenue is the workplace setting itself, where there exists a precedent for vaccination programs: annual flu shots. A CASE FOR WORKPLACE PROGRAMS As reviewed in Population Health Management in 2014, workplace primary care programs promote compliance with instituted mandates and are advantageous to both staff and employers. On-site clinics provide convenient opportunities for staff to be vaccinated on paid time, as workers may not have the financial security to take unpaid leave or do not have the means to travel to a community-based clinic. Many employees have chosen to telework or stay out of the labor market entirely due to health concerns for themselves or their families. A workplace vaccination program demonstrates an employer’s commitment to staff health and safety, thereby creating an environment where on-site staff feel secure and others may be more likely to return. While an employer must dedicate resources to run a clinic, previous studies have demonstrated that operational costs are offset by minimizing loss of productivity from staff who may otherwise become ill. For everyone’s benefit, the existing trust between staff and employers can be leveraged to reach those who are vaccine hesitant through targeted campaigns. In December 2020, the National Institutes of Health (NIH) piloted a COVID-19 workplace vaccination program with the goal of vaccinating 15,000 of its federal and contract staff in Bethesda, Maryland. The Commissioned Corps of the U.S. Public Health Service (USPHS) was activated to partner with the agency’s Occupational Medical Service (OMS) to design, implement, and operate a highly efficient COVID-19 workplace vaccination program. The clinic ultimately administered 31,415 doses in 120 days and only lost 25 (0.08 percent) doses due to storage or handling error. No doses were wasted until 97 days into the operation, after 27,000 doses were already administered, highlighting the clinic’s success.
At its inception, pop-up clinics in nontraditional settings provided some framework to build and operate a workplace clinic, but there was no precedent for mass vaccination during a public health emergency of this scale. Consequently, several challenges were presented. First, there were no guidelines for staffing, selecting a site, and operating with limited availability of COVID-19 vaccines. Second, infection control and safety protocols to protect clinic staff and patients (those receiving the vaccine) from COVID-19 in a mass vaccination setting were sparse. Third, an information management system to report site metrics to coordinating jurisdictions and manage employee medical records did not exist. Finally, the nation’s limited vaccine supply necessitated new protocols for tracking inventory and administering multiple manufacturers’ vaccines simultaneously. This article describes what we found to be key operational objectives that are clinically relevant and feasible in the workplace setting. PROGRAM DESIGN To establish an operational framework, the USPHS employed the Incident Command System (ICS), a proven model for coordinating emergency responses. This model is flexible in that management structure and operations can be adapted to the scale, complexity, and scope of an emergency. Incorporating personnel from various departments (facilities, pharmacy, clinical, security, and safety) introduced barriers to effective communication; these were negated through use of common terminology and objective-based management, both fundamental to the ICS framework. Other benefits of this model include a formal reporting system (the chain of command), a detailed staffing model with defined qualifications and responsibilities for each role, and appropriate staff-to-supervisor ratios to centralize efforts while ensuring safety and accountability.  All clinic staff, credentialed according to the institute’s standards, were subject to clinical competency assessments prior to onboarding. Before on-site orientation, clinic staff were introduced to mandatory safety measures, fit tested for N-95 respirators, and trained on donning and doffing personal protective equipment (such as face shields and gloves). Clinic staff received hands-on training in intramuscular administration techniques and how to operate safety devices for the several types of syringes used in the clinic. Orientation topics included CDC’s responses to FAQs regarding patient education, vaccine side effects, and protocols for managing high-risk patients. Clinicians then shadowed experienced peers and were observed before working independently. The clinic was conceived during a period of maximum telework; thus, a significant amount of unoccupied space was considered for hosting the operation. To determine the most appropriate location, sites were ranked based on functionality and environmental infection control factors. A modular configuration with outdoor waiting area, spacious observation seating, and separate entrance and exit for one-way patient flow was sought. Based on a 2016 study in Medical Care that found functional proximity significantly increased workplace influenza vaccination rates, a location central to campus, with accessibility and proper illumination, was also prioritized. Ventilation quality was quantified by the ratio of outdoor air exchange rate to personnel capacity. Finally, the availability of washable furniture with durable and nonporous surfaces for easy sanitization was also considered. The location ultimately selected was a vacant cafeteria in NIH’s Clinical Center (CC), which was complemented by an existing practice of pre-screening individuals for COVID-19 symptoms prior to entering the building. This checkpoint also issued fresh ASTM Level 3 surgical masks to all entrants; these masks were required to be worn within the facility, which was especially important to protect clinic staff and patients as local COVID-19 cases were high when the program was initiated. As this location’s occupant density was greater than that of other options, respirators were mandated for clinic staff because appropriate physical distance could not be ensured.
Figure 1. NIH COVID-19 Vaccine Clinic site metrics dashboard. A concise, auto-updating summary and visualization of vaccine clinic metrics easily updated and referenced by all clinic personnel. This may also be shared with staff to promote transparency and confidence in the workplace vaccine clinic. Template available upon request.

Click or tap on the figure to open a larger version in your browser.
DOCUMENTATION One of the critical aspects of operation was documentation, which was necessary for managing procedures within the clinic and reporting to coordinating jurisdictions (the state of Maryland, the U.S. federal government, and CDC). NIH’s CC Department of Clinical Research Informatics developed and integrated cloud-based platforms for scheduling patient appointments, maintaining wait lists, managing medical records, and tracking clinic inventory. Cumulative, manufacturer-specific, and extrapolated metrics, such as percent of patients with adverse reactions and percent of vials with additional doses, were summarized in a data dashboard accessible to all clinic staff and NIH leadership to monitor the program’s progress and success (see Figure 1). Metrics were used to optimize clinic operations to increase efficiency, including estimating the number of vials to thaw and clinical providers to schedule as a function of the number of appointments. The systems also enabled the clinic to scale based on vaccine supply, which was often uncertain.
MAXIMIZING EFFICIENCY WHILE OPERATING WITH UNCERTAINTY When vaccine rollout began in December 2020, federal inventory was significantly limited. It was unknown when, in what quantity, and which manufacturer’s vaccines would be allocated to jurisdictions. To avert these uncertainties, eligible patients were unable to self-schedule appointments until vaccines arrived. Upon arrival, the supply was split in half to ensure that second doses would be available within their recommended timeframes. With subsequent shipments, the number of vials reserved for second doses remained stocked, but vials with the earliest expiration dates were thawed for both first and second doses on a given day.
Second to safely vaccinating the entire NIH community, our goal was to minimize wasted doses. Unlike most other vaccines, Moderna and Pfizer’s COVID-19 vaccines have strict thawing protocols and short half-lives after thawing, and are stored in multi-dose vials (10- and 5-dose vials, respectively). These complications were compounded by the additional uncertainty of patient arrival time, walk-ins, doses lost to human error, or extra doses in vials. The more vials thawed, the greater the number of potential leftover doses; in a mass vaccination setting, this number could be staggering. A protocol was established to determine the minimum number of vials to thaw and predict the number of leftover doses based on the number of scheduled appointments, estimated number of unscheduled appointments, running percent of vials with additional doses, and average number of human errors. A waitlist was crucial for ensuring that the inevitable leftover doses were not wasted. After calculating the predicted quantity of leftover doses, clinic staff contacted that number of people on the waitlist and asked them to come to the clinic. It was made explicit to waitlisted patients that they were on standby should a dose become available, not guaranteed one.
TECHNIQUES TO INCREASE COMPLIANCE Finally, we employed consumer service techniques throughout the patient’s entire experience. Leadership’s goal was to have all questions and concerns answered so that staff could make an informed decision on whether to be voluntarily vaccinated. Virtual informational sessions were offered to educate staff on COVID-19, how the vaccines work, potential side effects, and vaccine misinformation. One-on-one conversations with providers from NIH’s Occupational Medical Service via a hotline were advertised and well-utilized by staff. OMS providers also followed up by phone with patients who did not return for their second dose within the recommended timeframe, thereby increasing the rate of compliance. We believe that providing as much information as possible at the start of the vaccination program increased staff’s comfort with receiving the vaccine and resulted in fewer missed appointments, less time spent in vaccination booths, and an increased vaccination rate. Lastly, extending clinic hours to accommodate all work shifts and permitting staff to schedule their own appointments respected their time and autonomy on what may be a sensitive topic.
CONCLUSIONS A significant tool to combat and hopefully end the COVID-19 pandemic is systematic global vaccination. We believe that workplace COVID-19 vaccination programs can serve as an alternative approach to bolster vaccination rates and alleviate stress on the existing public health system. Ameliorating this stress will permit redirection of time and resources to build the infrastructure necessary to increase accessibility on a global scale. We hope that our experience empowers workplaces to establish their own programs and that these tools can be broadly applied outside of the workplace setting to design and operate efficient COVID-19 vaccination programs.
ADRIANA E. GOLDING is a post-doctoral research fellow in the Section on Integrative Biophysics, Division of Basic and Translational Biophysics at the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, in Bethesda, Maryland.
CAPT. DEREK A. NEWCOMER is a commissioned officer in the U.S. Public Health Service and is the deputy director of the Division of Occupational Health and Safety at the Office of Research Services, National Institutes of Health, in Bethesda, Maryland.
JUDY L. CHAN is a nurse practitioner in the Occupational Medical Service, Division of Occupational Health and Safety at the Office of Research Services, National Institutes of Health, in Bethesda, Maryland.

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Acknowledgements The authors acknowledge the clinical staff and volunteers from NIH’s 27 institutes and centers, all of whom greatly contributed to the clinic’s overall success. Significant contributions of personnel and resources were provided by the following: Commissioned Corps of the USPHS; Occupational Medical Service; Office of Logistics and Acquisition Operations’ Division of Logistic Services; National Heart, Lung, and Blood Institute; Clinical Center’s Pharmacy Department and Department of Clinical Research Informatics; Office of Research Services’ Division of Occupational Health and Safety, Division of Emergency Management, and Division of Fire and Rescue Services; and Office of Research Facilities’ Division of Facilities, Operations, and Maintenance. We especially thank Dr. Jessica McCormick-Ell who oversaw the conception, coordination, and operation of the clinic and for providing a critical review of the article.
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